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Mapping Selasa, 22 Feb 2022
Mapping Selasa, 22 Feb 2022
REKAM MEDIK
UMUR JK LAMA RAWATAN
DIAGNOSA
Post gastrostomi per laparotomi a/I tumor intra oral infiltrasi esophagus POD III
Post MRM a/i Ca Mamae Sinistra T4bN0M0 post kemoterapi POD VI
Post Cholesistectomy perlaparoskopi a/i Cholelithiasis POD IV
Ca mamma dextra
Susp. Appendicitis
Ca Mammae Sinistra T4bN2M1 + Efusi Pleura Masif
post debridement POD 0 a/i Wound Infection Post Mastectomy, kemoterapi ke IV
Struma Nodusa Non Toxic Dextra POD 0
post eksisi a/i STT Mammae Dextra POD 0
Post Laparotomi a/i Ca Recti 1/3 Medial POD VI
Hernia Inguinalis Lateral Reponible
Susp. Tumor Malligna ar Punggung
Post ORIF K-Wire ar Digiti II Pedis Sinistra POD 0
Ca Laring
Adenocarcinoma Recti 1/3 medial + Anemia
Observasi Vomitus + Post Op Colostomy
Sarcoma et regio elbow dextra
Ulkus diabetikum a/r sinistra + dm tipe II
Efusi Pleura Masif POD 0
tumor colonorectal
soft tissue tumor+ orsitis
Masa tiroid+ febris + stroke iskemia
Ca Mammae sinistra susp Metastasis + Mechanical Injury ec Radioterapi ar Humerus Dextra
post debridement a/i ulkus diabetikum a/r pedis dextra+ dm tipe II + azotemia POD 0
gangren diabetikum a/r digiti 1 2 sinistra + DM Tipe II
Gangren diabetikum ar pedis dextra + DM tipe II
Post Debridement POD IV Post amputed POD II a/i Gangren Diabetikum ar Pedis Sinistra Digiti V + DMT2
PLANNING DPJP
Persiapan Kemoterapi ke 11, Terapi Cairan (RL/Futrolit/Kambivent), Diet Peptamin 6x200mg via gastrostomy Feedin SYF
GV/H dengan Gentamycin, vakum drain ADI
evaluasi KU, latihan duduk, aff kateter , nystatin amp, rencana pbj besok SYT
Konsul Paru, USG Abdomen ADI
USG Appendix ADI
Rontgen thorax, buang cairan 500cc/ hari (mulai besok pagi) MUF
observasi ku MUF
observasi ku, kontrol drain MUF
observasi ku, gv HDR
GV 2x/H, Observasi KU, Diet cairan SYT
Rencana Herniorrahpy (Selasa, 22 februari 2022) ADI
Perbaikan KU, Albumin 25% selama 3 hari (H2), transfusi darah ADI
Remove of Implant HDR
Kemoterapi (Selasa 22 februari 2022) MUF
Observasi KU + Rencana Kemoterapi (Selasa, 21 Februari 2022) ADI
Observasi KU + Cek KGDS ADI
eksisi MUF
transfusi 2 bag MUF
rontgen thorax SYT
transfusi 2bag, perbaiki ku HDR
eksisi MUF
lab faal tiroid, RO Thorak ADI
GV/H dengan NaCl dan gentamisin salep, Konsul Ke Paru ADI
GV/ Hari, perbaikan ku, rawat luka HDR
observasi ku AND
debridement (selasa, 22 februari 2022) HDR
GV/H, KGDS/H ADI